MR-5, Mod. 1-Inst. Page 1 of 4Revised 7/02

MR-5 Instructions

MODULE 1

THE APPLICANT MUST SUBMIT A JOINT ARTICLE 3 or 4 / NPDES PERMIT APPLICATION BEFORE THEY CAN REFERENCE ANY MATERIALS AS BEING FOUND IN THE ARTICLE 3 or 4 APPLICATION. ALL MATERIALS REFERENCED MUST BE IN THE JOINT ARTICLE 3 or 4/NPDES APPLICATION SUBMITTED, NOT IN PREVIOUSLY SUBMITTED APPLICATIONS

Module 1:General Information

This Module is to be completed and submitted with all applications for new permits or reissuance of permits. Excerpts from this module may be required to be addressed in modifications or transfers also if they are effected by those applications.

Heading Information

Box 1Enter WVDEP regional office number.

Box 2Enter initial date the application is submitted and the dates of each successive submission with corrections.

Application Type, Fees & Hydrologic Region

Row 1: Mark an “X” in all boxes that describe what is requested with this application. Include the Reissuance number and the transfers number if applicable. Theses numbers represent how many times the NPDES permit has been reissued or transferred since it was originally issued. If “Abandon” is marked be sure to also mark “Modification” box and include a number.

Row 2:Provide the “Required reissuance filling date” in the space provided (this is 120 calendar days prior to the expiration date found on page one of the latest issuance of the permit), or mark “NA” if the app. is for a new permit.

Row 3:This row is used to show the required fees for NPDES permits that cover facilities requiring Article 3 permits. If this is an application for a new permit or reissuance mark the $1000.00 box. If it is a modification application mark the $500.00 box.

Row 4:This row is used to show the required fees for NPDES permits that cover facilities that do not require Article 3 permits. Provide the last date the annual NPDES fees were paid in the first space provided (if this is an application for a new permit enter “N/A”). Provide the calculated application fee required for this application and include the fee schedule worksheet at the end of this module.

Only certified or cashier checks, and money orders made payable to “West Virginia Division of Environmental Protection” will be accepted for the filing fees required. If the FULL amount of the filing fee required is not submitted upon receipt of the application it will not be logged in or reviewed until the full fee payment is made.

Row 5: This row is used to show the hydrologic region of the facility used by the “WV Watershed Management Project”. In the first blank enter the eight (8) digit code, and in the second enter the name of the “Hydrologic Region”. These “WV Watershed Management Project” codes and names are available at WVDEP regional offices.

Part I:Applicant Owner (Operator) Information

A.The applicant shall be the entity that owns the Article 3 or 4 permit(s) or other operations to be covered by this application. This is the name the permit will be issued to. Fill in the Applicant’s (owner’s) information in the spaces provided (if Mailing Address is P.O. address include Street Address also).

B.Mark an “X” in the box that describes the type of ownership of the applicant.

PART II:Facility Information

A.Enter the name of the mine(s) or complex.

Enter the mailing address as in Part I-A (if the address is the same as in Part I-A just enter “SEE PART I-A”).

Enter all counties in which the facility is located.

Enter the nearest post office based on straight-line distance from the center of the surface disturbance.

On the two lines under “Physical Location” enter a description of how to get to the facility and where it is located. Start at the nearest town (must be found on the county road map or USGS topographic map) to the access road entrance, then use the route number(s) from the nearest town with a compass direction and distance until the entrance to the facilities access road is reached. In addition state the name of the hollow, stream or mountain on which the facility is located. If the permit covers a complex of several mines/sites then the directions should be to the main field office for the complex. (Example: From Ciro, Rt.4 S. 1.2 miles to Rt. 4/20 E. 5 miles to access rd. The site is located up Bowyer Creek on Trace Ridge)

PART II:Facility Information (continued)

Facility Contact must be an employee of the applicant, and must be thoroughly familiar with the operation of the facility, such as chief engineer, plant manager, superintendent, etc., but not a consultant. Include the title and phone number of the Facility Contact also.

Mark an “X” in the box that describes the type of facility the permit is covering. If both types of sources exist mark both and include an explanation labeled as “Attachment 1-II-B”.

C.In the first column (Permitting Action Requested) mark an “X” in the box that describes the type of application being processed. In the second column (Operations Covered) enter every type of operation this application is covering. Break down the operations into types and enter in the appropriate sub-column as follows:

“Operate” Enter all types of active operations that apply.

“Remine” Enter the type of abandoned operation(s) under the CWA Sec. 301(p) that apply.

“Abandon” Enter the type of operation(s) that have been abandoned and/or you request to abandon with this application.

D.Mark an “X” in the all the boxes that describe the type of activities that will be conducted on any of the operations listed in Part “C”.

Part III:Reissuance of Existing Permits

A.If this is an application for a new NPDES permit mark an “X” in the “N/A” box. If this is a reissuance application include a history of all changes to the permit that have been submitted to WVDEP since it was last reissued (or originally issued). Be sure to include any changes to the permit requested in this application and to label it as “Attachment 1-III-A”. Use the following format:

ATTACHMENT 1-III-A
PERMIT HISTORY
Modification # 1 / Approved: 10/23/94
Add U-3046-92 with bathhouse; Add outlets 008,009, 101
Modification # 2 / Withdrawn: 1/15/95
Abandon U-3046-92; delete outlets 009,101; move outlet 008; Add use of ammonia and pH to 10.5 at outlet 005
Modification # 3 / Approved: 10/23/94
Abandon U-3046-92; delete outlets 009,101; move outlet 008
Transfer # 1 / Approved: 10/23/94
From: Little Coal Co. To: Big Coal Co.
changes Requested WITH THIS APPLICATION
Modification # 4, Transfer # 2 / Pending
From: Big Coal Co. To: Bigger Coal Co.; Post mining limits for 001 - 005; delete 006, 007

Part IV:SIC Code

A.Mark all codes that apply to the operation(s) at the facility.

PART V:Environmental Permits

A.Enter the permit/ID number, date of issuance and expiration date of all environmental permits required for the operation of this facility in the table provided. Address all of the preprinted permits at a minimum by entering complete data or entering “N/A” in the “Permit or ID Number” column.

If the applicant is accepting responsibility for some (or all) of the discharge from any operations (a) not owned by the applicant, or (b) not fully covered by this application, then enter the appropriate identification number followed by “/R” and the dates. (Example: S-40021-94/R, Q-1024-86/R, Quincy Siding /R) Likewise if someone else is accepting responsibility for some of the discharge from operations of the applicant that are covered by this application, then enter that NPDES permit number followed by “/R’ (Example: WV1010345/R) and the dates. If either of these situations exist a “Module 1R” signed by the party responsible for the final outlet must be included with the application.

Part VI:Map (Exhibit 1-VI-A)

Submit a topographic map, labeled “Exhibit 1-VI-A”, with a minimum contour accuracy of that shown on the latest available 7.5 min. quadrangle maps published by the U. S. Geologic Survey. The “Proposal”, “Drainage” or “Subsidence Survey” map submitted for the Article 3 permit application may be used to show this information, but only if it is submitted in a joint application and is of sufficient scale to clearly show all the NPDES and Article 3 requirements. If the size of the operation requires multiple maps be submitted, label the maps as 1 of 3, 2 of 3 etc. and use match lines. The map must show all manmade structures and be of a reasonable scale that can clearly shows the requirements outlined below.

Part VI:Map (Exhibit 1-VI-A) (continued)

1.Clearly show the individual boundary limits of every operation to be covered, and adjacent operations. Label each with their Article 3 or 4 permit number. Color operational areas using the color code shown in “A-8” below.

2. Show all physical (sediment control), chemical, sewage, biological and passive treatment systems that treat discharge from this facility. If any flow/discharge from this facility is treated and/or discharged through an outlet of another facility then show that outlet on the map and include the NPDES Permit number also. Label each treatment system to correspond to the construction plans and the “Exhibit 2-II-A” flow chart.

3. Show all intake points, outlets (discharge points), and all internal, ground water or in-stream monitoring points. Label each with the appropriate symbol in orange and numbered accordingly (if an outlet is permitted under a different facility include NPDES permit number):

(a) Intakes (water supplies) - use “I” followed by a two digit number EX: “I05”

(b) Normal Outlets or Monitoring points - use a three digit number from 001 to 199

(d) Passive Treatment Outlets or Monitoring Points - use a three digit number from 300 to 399

(e) Sewage Outlets or Monitoring Points - use a three digit number from 400 to 499

(f) Raw Water Monitoring Points - use a three digit number from 500 to 599

(g) Ground Water Monitoring Points - use “G” followed by a two digit number EX: “G05”

(h) In-stream Monitoring Points - use a “U” for upstream or a “D” for downstream followed by the stream’s initials (if it is an unnamed tributary of a stream the first initial is to be a “U”), and then a number if needed for multiple points on the same stream. EXAMPLE: The most upstream point on Clear Creek may be “UCC1”; a downstream point on an unnamed tributary of Clear Creek may be “DUCC2”.

4. Label and show all streams, creeks, rivers, lakes or other surface bodies of water within the boundary of the facility and 1,000 ft. beyond.

5. Show all seeps, springs or other ground water discharge points (natural or man made).

6. Show all types of water wells (drinking, domestic use, ground water monitoring), and any type of production, injection or abandoned commercial wells.

7. Delineate all wellhead protection areas.

8. Delineate all wetlands known to the applicant.

9. Include a legend with the map using the following symbols and/or color codes, as well as those symbols used by the USGS on their 7.5 Min. quadrangle maps (If this is to be a GPP map also, then insure all GPP symbols are also shown):

ITEM ON MAP / SYMBOL / COLOR CODE
Outlet /  002 / Solid ORANGE triangle
Instream Monitoring Points /  DUCC2 / Solid ORANGE circle with X
Internal Monitoring Point /  003 / Empty BLACK triangle
Intake (Water Supply) Point /  I05 / Empty BLACK box
Wetlands / (Dotted line around USGS Marsh or Swamp Symbol )
Proposed or Disturbed Areas / YELLOW
Regraded & Seeded Areas / GREEN
Drainage Structures / BLUE
Adjacent Operations / PURPLE

10. Delineate all wetlands known by the applicant to exist prior to any disturbance by the applicant.

11. Provide a title block for each map or supplemental map that is to be used to show the requirements for the “Exhibit 1-VI-A” map to include:

(a) The title “EXHIBIT A” if using supplemental maps, title as “Exhibit 1-VI-A, Map 1 of 3 (or 2 of 3, etc.)”. If “EXHIBIT 1-VI-A” map is also GPP Map, Drainage Map, or Proposal Map insure all titles are shown.

(b) The facility name (to match what was used in Module 1, Part II, Sec. A),

(d) The counties and districts the facility is located in,

(e) The map scale,

(f) The NPDES permit No.,

(g) The Article 3 or 4 permit Number(s) covered by the NPDES No.

(h) The date the map was completed

(i) Type of NPDES application with number (EXAMPLES: “PROPOSED NEW NPDES PERMIT”, “NPDES REISSUANCE # 2” or “NPDES MODIFICATION # 3”).

Part VI:Map (Exhibit 1-VI-A) (continued)

12. Provide a location map with the same details and scale as that of the 1 inch to 1 mile scale DOH county road map. It must be a minimum of 4 inches by 4 inches in size and show:

(a) The location of the facility,

(b) The center of the facility depicted by latitude and longitude lines crossing at the center with the coordinates on those lines.

13. Provide a North arrow on the map for orientation along with the general strike and dip of the regional strata.

14. If this map is to be the Groundwater Protection Map locate all items shown in “Table 14-I-A” on the map and label them by their ID# shown in that table.

PART VII:Transfers and additional Responsibilities

A.This part addresses discharging through another facility, accepting discharge from another facility or transferring the responsibility of the “Ground Water Protection Plan’ with this application.

1. If proposing to either (a) have flow effected by this facility discharged through a different facility (NPDES permit) or (b) have flow effected by a different facility discharged through this facility (NPDES permit) then include a signed and notarized “Module 1R”(Responsibility for Discharge from Others). If a “Module 1R” has been previously submitted (and the conditions have not changed) then it is not required to resubmit another one. A copy of “Module 1R” with original signatures must be submitted in each of the NPDES permits that are effected by it.

2. If this application is transferring the ownership of the NPDES permit the responsibility for the “Ground Water Protection Plan” must be addressed. If the responsibility is changing include a “MR-5GT” transfer form with the application.

PART VIII:Applicant Certification

A.The application must be certified in accordance with title 47, Series 30, Section 4.7.1 of the WV NPDES regulations, and the signature must be dated and notarized. If the application is corrected or changed after initial submission it must include an updated certification when resubmitted for review. Authorized signatures for each type of applicant ownership include:

OWNERSHIP TYPE / AUTHORIZED SIGNATURES
Corporation / President, Secretary, Treasurer, Vice-President, or any other person performing similar policy or decision-making functions for the corporation, or Manager of facilities employing more than 250 persons or have gross annual sales or expenditures exceeding $25,000,000 (in 2nd Qrt. 1980 dollars), if authority to sign documents has been granted to the manager by the corporation.
Partnership / General Partner
Sole Proprietorship / Proprietor

For signatures other than principle officers, partners, or sole proprietors appropriate documentation granting or verifying such signatory authority must be included with the application.